Drug Shortages Still Vex Anesthesiology

Drug Shortages Still Vex Anesthesiologists

Editor's Note:

Anesthesiologists have been hit hard by pharmaceutical shortages. In April 2011, the American Society of Anesthesiologists (ASA) surveyed its members on drug shortages. Among the key findings, 90.4% of respondents reported that they were currently experiencing a shortage of at least 1 anesthesia drug, and 98.1% reported that they had experienced a shortage of at least 1 anesthesia drug in the previous year.

We asked the ASA for an update and were put in touch with Jeff Jacobs, MD, Chair of the ASA's Committee on Ethics and a staff anesthesiologist at the Cleveland Clinic in Weston, Florida. It is clear that drug shortages remain a critical issue for anesthesiologists, their hospitals, and their patients.

What Has Changed Since Last Year?

Medscape: What has changed since last year and since the member survey?

Dr. Jacobs: One thing the ASA has done that is very helpful for its members and our patients is to identify issues and to intervene to try to solve some of these issues. The survey the ASA conducted showed that the problem is pervasive, affecting major institutions like the Cleveland Clinic and the small mom-and-pop surgery centers.

Unlike sporadic reports and just talking to our friends, the ASA helped everyone recognize that this is a crisis for the efficient and safe delivery of anesthesia. As a result of that, we were able to take the next steps -- for example, supporting legislation and bringing the FDA into the mix. One of the things that has changed for the better is that there is a recognition and an identification of potential solutions.

Medscape: What are the solutions, then? Could you describe a handful of steps that could be taken?

Dr. Jacobs: The problem is that each drug shortage has a unique cause, so there is not a magic-bullet solution.

Dr. Jeff Jacobs, Chair of the ASA's Committee on Ethics, says drug shortages are a continuing problem in anesthesiology.

But by bringing everyone together, we recognized some of the problems for which we hope to create some of the solutions. For example, there might be an issue with redundancy; in the past there were many, many drug manufacturers producing drug X. Whether it was for economic reasons, or for manufacturing-offshore reasons, or for plant-contamination reasons, there are only 1 or 2 companies now that manufacture drug X.

So, for example, all of a sudden one of those product lines has a small contaminant and the FDA closes it until the problem is corrected. Suddenly there is no drug available, or there's much less. And if that happens for certain injectable medications that we use in the operating room every day, you can imagine the fallout, the potential risk, which is why it's so important to have a physician anesthesia provider.

Part of our training in residency and our background from medical school is to understand that there might be options available to substitute for those medications in the short term. Some with less training or less experience might be comfortable using just 1 specific medication, and when in short supply there might not be alternatives in that person's mind.

I can give you a great example that happened to me today in the operating room. I had a patient whose blood pressure and heart rate were high, so she needed a medication, an intravenous medication, to bring her blood pressure and heart rate within a normal range. Our anesthesiology extenders, let's say a nurse anesthetist, are very capable and skilled professionals in the operating room but with a narrower knowledge base. They will want to reach for the basic drugs that we always use to take care of that.

Well, the 2 most common drugs we use to take care of that are both in short supply nationally, and our hospital hasn't had them for several weeks. So I needed to choose an alternative because my nurse anesthetist had no ideas. I gave her a couple of ideas for drugs that we could use instead that would be safe alternatives. Without my presence, this could have resulted in a problem. Having the anesthesiologist there makes it more important when the usual method is not an option.

Ethical Considerations

Medscape: What other solutions are we talking about?

Dr. Jacobs: As Chair of the ASA Committee on Ethics, I'm working with the Emory (Atlanta) Department of Ethics to put together a consensus conference on the ethical impact of drug shortages. It's targeted for mid- to late June.

We are going to identify and answer some of the ethical issues of drug shortages. For example, if there is 1 case of medication left, who should get that case of medicine? Should it be the person or hospital that pays the most or that pays the fastest, or should that medication go to a center of excellence?

Another example would be transplant rejection medicine. Why are we doing transplants right now if we don't have enough antirejection medication for those who have already received transplants?

Part of the reason for this is because as physicians, we get a lot of bad press about being in bed with the pharmaceutical companies and taking kickbacks -- conflicts of interest. Taking a look at this topic really allows the public to see that we're not in it for the money; we're really in it for the safety of the patient and the safety of society. I have no financial stake in it and the ASA has no financial stake in it.

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